ANDREWS ISD BENEFIT GUIDE EFFECTIVE: 09/01/2022 8/31/2023 WWW.MYBENEFITSHUB.COM/ANDREWSISD 2022 - 2023 PlanYear 1
Table of Contents FLIP TO... How to Enroll 4 5 Annual Benefit Enrollment 6-9 1. Section 125 Cafeteria Plan Guidelines 6 2. Annual Enrollment 7 3. Eligibility Requirements 8 4. Helpful Definitions 9 Dental 10 11 Vision 12 Cancer 13 14 Accident 15-16 Identity Theft 17 Disability 18-19 Life and AD&D 20 21 Hospital Indemnity 22-23 Critical Illness 24 25 Emergency Medical Transportation 26 Telehealth 27 HOW TO ENROLLPG. 4 SUMMARYPAGESPG. 6 BENEFITSYOURPG. 10 2
Benefit Contact Information ANDREWS ISD BENEFITS DENTAL VISION Financial Benefit Services (800) 583 www.mybenefitshub.com/andrewsisd6908 Lincoln Financial Group Group #00001D039766 (800) 423 www.lfg.com2765 Superior Vision Group #38524 (800) 507 www.superiorvision.com3800 CANCER ACCIDENT IDENTITY THEFT American Public Life (800) 256 www.ampublic.com8606 Mutual of Omaha Group #GPS3466429 (800) 775 www.mutualofomaha.com8805 www.IDWatchdog.com(800)IDWatchdog7743772 DISABILITY LIFE AND AD&D HOSPITAL INDEMNITY www.oneamerica.com(855)GroupOneAmerica#6187395176365 Lincoln Financial Group Group #400254877 (800) 423 www.lfg.com2765 The www.TheHartford.com(866)GroupHartford#VHI8880935474205 CRITICAL ILLNESS EMERGENCY TRANSPORTATION TELEHEALTH The www.TheHartford.com(866)GroupHartford#VCI8880935474205 (800)MASA423 www.masamts.com3226 (888)MDLive365 landing_homehttps://members.mdlive.com/fbs/1663 3
Employee benefits made easy through the FBS Benefits App! AllYour BenefitsOne App OR SCAN Text “FBS ANDREWS” to (800) 583-6908 App Group #: FBSANDREWS Text “FBS ANDREWS” to (800) 583-6908 and get access to everything you need to complete your benefits enrollment: • Benefit Resources • Online Enrollment • Interactive Tools • And more! 4
1 www.mybenefitshub.com/andrewsisd How to Log In 2 CLICK LOGIN 3 ENTER USERNAME & PASSWORD Your Username Is: Your email in THEbenefitsHUB. (Typically your work email) Your Password Is: Four (4) digits of your birth year followed by the last four (4) digits of your Social Security Number If you have previously logged in, you will use the password that you created, NOT the password format listed above. 5
An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent status.
(CIS):STATUS QUALIFYING
Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of your qualifying event and meet with your Benefit Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event. IN EVENTS
Change in Number of Tax Dependents
Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.
6
Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.
EligibilityDependents'ofStatus
Judgment/Decree/Order
A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).
Section 125 Cafeteria Plan Guidelines SUMMARY PAGESAnnual Benefit Enrollment CHANGES
A Cafeteria plan enables you to save money by using pre tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer.
Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.
Eligibility for Government Programs
Marital Status
Change in Status of Employment Affecting Coverage Eligibility
A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.
If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.
Gain/Loss
During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs.
For benefit summaries and claim forms, go to the Andrews ISD benefit www.mybenefitshub.com/andrewsisdwebsite:. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3 4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.
• Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.
All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligible employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.
Howsection.can I find a Network Provider?
SUMMARY PAGESAnnual Benefit Enrollment 7
Q&A Who do I contact with Questions?
For benefit questions, you can contact your Benefit Office or you can call Financial Benefit Services at (866) 914 5202 for assistance. Where can I find forms?
• Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.
• Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.
Annual Enrollment
New Hire Enrollment
For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/ andrewsisd. Click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms
Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent Disclaimer:eligibility.
Employee RequirementsEligibility
Life w/AD&D
Vision To
Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse Potentialeligibility.Dependent
Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.
Dependent RequirementsEligibility
AD&D
Cancer
Please
You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.
PLAN MAXIMUM AGE Dental To
Supplemental Benefits: Eligible employees must work 30 or more regularly scheduled hours each work week. Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2022 benefits become effective on September 1, 2022, you must be actively at work on September 1, 2022 to be eligible for your new benefits.
Critical Illness
If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your Benefit Office to request a continuation of coverage. age 26 age 26 To age 26 To age 26 To age 26 To age 25 note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents.
SUMMARY PAGESAnnual Benefit Enrollment 8
Calendar Year
In Network Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider. Out of Pocket Maximum
January 1st through December 31st Co-insurance any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. Coverage
Guaranteed
Plan Year 1st through August 31st Pre Existing Conditions
After
SUMMARY PAGESHelpful Definitions 9
September
The most an eligible or insured person can pay in co insurance for covered expenses.
Annual
The period during which existing employees are given the opportunity to enroll in or change their current elections. Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.
The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively at work and/or pre existing condition exclusion provisions do apply, as applicable by carrier.
Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescription drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).
You are performing your regular occupation for the employer on a full time basis, either at one of the employer’s usual places of business or at some location to which the employer’s business requires you to travel If you will not be actively at work beginning 9/1/2022 please notify your benefits administrator. Enrollment
Actively at Work
ABOUT DENTAL Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, dental treatment and Fordisease.fullplan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Dental Insurance Lincoln Financial Group EMPLOYEE BENEFITS HIGH LOWThe Lincoln Dental Connect® PPO Plan Contracting Dentists NonDentistsContracting Contracting Dentists NonDentistsContracting Calendar (Annual) Deductible Individual: $50 Family: $150 Waived for: Preventive Individual: $50 Family: $150 Waived for: Preventive Individual: $50 Family: $150 Waived for: Preventive Deductibles are combined for basic and major Contracting Dentists’ services. Deductibles are combined for basic and major Non Contracting Dentists’ services. Annual Maximum $1,500 $1,500 $1,500 $1,500 Annual Maximums are combined for preventive, basic, and major services. Lifetime Orthodontic Max $1,500 $1,500 $1,500 $1,500 Orthodontic Coverage is available for dependent children. Waiting Period There are no benefit waiting periods for any service types Preventive Services Contracting Dentists Non Contracting Contracting Dentists Non Contracting Routine oral exams Bitewing X rays Full mouth or panoramic X rays Other dental X rays (including periapical films) Routine cleanings Fluoride treatments Space maintainers for children ProblemSealants focused exams 100% No Deductible 100% No Deductible 90% No Deductible 90% No Deductible DentalHigh Low Employee Only $31.74 $25.53 Employee and Spouse $62.66 $50.24 Employee and Child(ren) $83.58 $70.83 Employee and Family $124.60 $104.42 10
EMPLOYEE BENEFITS Dental Insurance Lincoln Financial Group Basic Services Contracting Dentists Non Contracting Contracting Dentists Non Contracting Consultations Palliative treatment (including emergency relief of dental pain) Injections of antibiotics and other therapeutic medications Fillings Prefabricated stainless steel and resin BiopsySimplecrownsextractionsandexamination of oral tissue including brush biopsy General anesthesia and I.V. sedation (High Plan Only) Oral surgery (High Plan Only) 80% After Deductible 80% After Deductible 50% After Deductible 50% After Deductible Major Services Contracting Dentists Non Contracting Contracting Dentists Non Contracting FullBridgesExtractionsSurgicalandpartial dentures Denture reline and rebase services Crowns, inlays, onlays, and related Implantservices& implant related services (High Plan Only) General anesthesia and I.V. sedation (Low Plan Only) Oral surgery (Low Plan Only) 50% After Deductible 50% After Deductible 50% After Deductible 50% After Deductible Orthodontics Contracting Dentists Non Contracting Contracting Dentists Non Contracting Orthodontic exams X StudyExtractionsraysmodelsAppliances 50% 50% 50% 50% Contracting Dentists/Non Contracting Dentists: Visit www.LincolnFinancial.com/FindADentist to find a contracting dentist near you. This plan lets you choose any dentist you wish. However, your out of pocket costs are likely to be lower when you choose a contracting dentist. For example, if you need a crown Contracting Dentists: you pay a deductible (if applicable), then 50% of the remaining discounted fee for PPO members. This is known as a PPO contracted fee. Non Contracting Dentists: you pay a deductible (if applicable), then 90% of the usual and customary fee, which is the maximum expense covered by the plan. You are responsible for the different between the usual and customary allowance and the dentist’s billed USUALcharge.ANDCUSTOMARY (U&C): the maximum expense covered by the Policy. U&C allowances are based on dental charge information collected by nationally recognized industry databases. U&C allowances are reviewed and updated periodically. If Covered Expenses are Incurred outside the United States, the U&C allowance will be the amount that would be allowed for that procedure if it had been performed at the Company's Group Insurance Service Office in Omaha, Nebraska. U&C allowances may be higher or lower than the fees charged by a Dentist. U&C is not an indication of the appropriateness of the Dentist's fee. Instead, U&C is a variable plan provision used to determine the extent of coverage provided by the Policy. 11
ABOUT VISION Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses. For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Vision Insurance Superior Vision EMPLOYEE BENEFITS Services/FrequencyCopays Exam $10 Exam 12 months Materials1 $25 Frame 12 months Contact lens fitting $25 Contact lens fitting 12 months Lenses 12 months Vision Employee Only $8.05 Employee and Spouse $16.09 Employee and Child(ren) $19.02 Employee and Family $29.12 Benefits through Superior National network In Network Out of Network Exam (ophthalmologist) Covered in full Up to $42 retail Exam (optometrist) Covered in full Up to $37 retail Frames $150 retail allowance Up to $60 retail Contact lens fitting (standard2) Covered in full Not covered Contact lens fitting (specialty2) $50 retail allowance Not covered Lenses (standard) per pair Single vision Covered in full Up to $26 retail Bifocal Covered in full Up to $34 retail Trifocal Covered in full Up to $50 retail Progressives lens upgrade See description3 Up to $50 retail Contact lenses4 $150 retail allowance Up to $100 retail Co pays apply to in network benefits; co pays for out of network visits are deducted from reimbursements. 1 Materials co pay applies to lenses and frames only, not contact lenses 2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/ or a member who wear toric, gas permeable, or multi focal lenses. 3 Covered to provider’s in office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co pay. 4 Contact lenses are in lieu of eyeglass lenses and frames benefit Discount features Look for providers in the provider directory who accept discounts, as some do not; please verify their services and discounts (range from 10% 30%) prior to service as they vary. Discounts on covered materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options Specialty contact lens fit: 10% off retail, then apply allowance Discounts on non covered exam, services, and materials Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, miscellaneous options: 20% off retail Disposable contact lenses: 10% off retail Retinal imaging: $39 maximum out of pocket Refractive surgery Superior Vision has a nationwide network of independent refractive surgeons and partnerships with leading LASIK networks who offer members a discount. These discounts range from 10% 50%, and are the best possible discounts available to Superior Vision. How to Print your Vision ID Card: You can request your vision id card by contacting Superior Vision directly at (800) 507 3800. You can also go to www.superiorvision.com and register/login to access your account by clicking on “Members” at the top of the page. You can also download the Superior Vision mobile app on your smart phone. 12
ABOUT CANCER Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment. For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Cancer Insurance American Public Life EMPLOYEE BENEFITS Cancer Treatment Policy Benefits LowLevelPlan1 HighLevelPlan3 Radiation Therapy, Chemotherapy, Immunotherapy Maximum per 12 month period $10,000 $15,000 Hormone Therapy Maximum of 12 treatments per calendar year $50 per treatment $50 per treatment Experimental Treatment paid in same manner and under the same maximums as any other benefit Cancer Screening Rider Benefits Level 1 Level 1 Diagnostic Testing 1 test per calendar year $50 per test $50 per test Follow Up Diagnostic Testing 1 test per calendar year $100 per test $100 per test Medical Imaging per calendar year $500 per test/1 test per calendar year $500 per test/1 test per calendar year Surgical Rider Benefits Level 1 Level 4 Surgical $30 unit dollar amount Max $3,000 per operation $45 unit dollar amount Max $4,500 per operation Anesthesia 25% of amount paid for covered surgery Bone Marrow Transplant Maximum per lifetime $6,000 $9,000 Stem Cell Transplant Maximum per lifetime $600 $900 Prosthesis Surgical Implantation/Non Surgical (not Hair Piece) 1 device per site, per lifetime $1,000 / $100 $2,000 / $200 GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Treatment for cancer is often lengthy and expensive. While your health insurance helps pay the medical expenses for cancer treatment, it does not cover the cost of non medical expenses, such as out of town treatments, special diets, daily living and household upkeep. In addition to these non medical expenses, you are responsible for paying your health plan deductibles and/or coinsurance. Cancer insurance through American Public Life helps pay for these direct and indirect treatment costs so you can focus on your health. Summary of Benefits Cancer Employee Only $18.36 Employee and Spouse $35.66 Employee and Child(ren) $25.26 Employee and Family $39.80 13
Patient Care Rider Benefits Level 1 Level 1 Hospital Confinement: Per day of Hospital Confinement (1 30 days) Per day for Eligible Dependent Children (1 30 days) Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent Children (31+days) $200$100$200$100 $200$100$200$100 Outpatient Facility Per day surgery is performed $200 $200 Attending Physician Per day of Hospital Confinement $30 $30 Dread Disease Per day of Hospital Confinement (1 30 days / 31+ day) $100 / $100 $100 / $100 Extended Care Facility Up to the same number of Hospital Confinement Days $100 per day $100 per day Donor $100 per day $100 per day Home Health Care Up to the same number of Hospital Confinement Days $100 per day $100 per day Hospice Care Up to maximum of 365 days per lifetime $100 / $100 $100 / $100 US Government, Charity Hospital or HMO Per day of Hospital Confinement (1 30 days/ 31+ days) $100 / $100 $100 / 100 Miscellaneous Care Rider Benefits Level 1 Level 1 Cancer Treatment Center Evaluation or Consultation 1 per lifetime Not included $750 Evaluation or Consultation Travel and Lodging 1 per lifetime Not Included $350 Second / Third Surgical Opinion per diagnosis of cancer $300 / $300 $300 / $300 Drugs and Medicine Inpatient / Outpatient (maximum $150 per month) $150 per confinement $50 per prescription $150 per confinement $50 per prescription Hair Piece (Wig) 1 per lifetime $150 $150 Transportation Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane, or train Travel by car Lodging up to a maximum of 100 days per calendar year actual coach fare or $0.40 per mile $0.40 per mile $50 per day actual coach fare or $0.75 per mile $0.75 per mile $100 per day Family Transportation Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Family Lodging up to a maximum of 100 days per calendar year actual coach fare or $0.40 per mile $0.40 per mile $50 per day actual coach fare or $0.75 per mile $0.75 per mile $100 per day Blood, Plasma and Platelets $300 per day $300 per day Ambulance Ground/Air Maximum of 2 trips per Hospital Confinement for all modes of transportation combined $200 / $2,000 per trip $200 / $2,000 per trip Inpatient Special Nursing Services per day of Hospital Confinement $150 per day $150 per day Outpatient Special Nursing Services Up to same number of Hospital Confinement days $150 per day $150 per day Medical Equipment Maximum of 1 benefit per calendar year Not included $150 Physical, Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year $25 per visit / $1,000 $25 per visit / $1,000 Waiver of Premium Waive Premium Waive Premium Internal Cancer First Occurrence Rider Benefits Level 1 Level 2 Lump Sum Benefit Maximum 1 per Covered Person per lifetime $2,500 $5,000 Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime $3,750 $7,500 Hospital Intensive Care Unit Rider Benefits Intensive Care Unit $600 per day $600 per day Step Down Unit Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit $300 per day $300 per day Cancer Insurance American Public Life EMPLOYEE BENEFITS Should you need to file a claim contact APL at (800) 256 8606 or online at www.ampublic.com 14
ABOUT ACCIDENT Do you have kids playing sports, are you a weekend warrior, or maybe accident prone? Accident plans are designed to help pay for medical costs associated with accidents and benefits are paid directly to you. For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Accident Insurance Mutual of Omaha EMPLOYEE BENEFITS ELIGIBILITY ALL ELIGIBLE EMPLOYEES ENROLLED IN THE HIGH PLAN Eligibility Requirement You must be actively working a minimum of 30 hours per week to be eligible for coverage. Dependent Eligibility Requirement To be eligible for coverage, your dependents must be able to perform normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself. Premium Payment The premiums for this insurance are paid in full by HIGHyou.PLAN LOW PLANPLAN CoverageINFORMATIONType 24 hour (On and off job) 24 hour (On and off job) Express Benefit $100 $50 Annual Benefit Maximum (ABM) Not Included Not Included Portability Included Included BENEFITS HIGH PLAN LOW PLAN Initial Care & Emergency1 Most treatment / service required within 72 hours of accident; Once per accident per insured person Emergency Room $200 $100 Urgent Care Center $125 $75 Initial Physician Office Visit $100 $50 Ambulance Up to $1,500 Up to $500 Specified Injuries1,2 Fractures (Surgical / Non surgical) Up to $6,000/Up to $3,000 Up to $3,000/Up to $1,500 Dislocations (Surgical / Non surgical) Up to $9,000/Up to $4,500 Up to $3,000/Up to $1,500 Lacerations Up to $800 Up to $400 Burns Up to $15,000 Up to $5,000 Dental Up to $300 Up to $150 Hospital, Surgical & Diagnostic1,3 Admission $1,500 $750 Daily Confinement (Up to 365 days per accident) $300 per day $100 per day ICU Confinement (Up to 15 days per accident) $600 per day $300 per day Rehab. Facility Confinement (Up to 30 days per accident) $150 per day $50 per day Surgical Up to $2,000 Up to $1,000 Diagnostic Up to $300 Up to $100 AccidentHigh Plan Low Plan Employee Only $15.08 $6.37 Employee and Spouse $23.55 $9.91 Employee and Child(ren) $29.91 $13.04 Employee and Family $39.82 $17.23 15
Additional Benefits1 Benefits are payable within 365 days of accident
When does this insurance end? Insurance will end on the last day of the month in which an insured person no longer satisfies the applicable eligibility conditions, or when you reach the age of 80. Additional circumstances under which insurance will end are described in the certificate.
Accident Insurance Mutual of Omaha EMPLOYEE BENEFITS
Physician Follow Up Office Visit $100; Up to 2 per accident $50; Up to 2 per accident Therapy Services $50; Up to 6 per accident $25; Up to 6 per accident Medical Device $200 $50
BENEFITS
Can I take this insurance with me if I change jobs / am no longer a member of this group? In the event this insurance ends due to a change in your employment / membership status with the group, or for certain other reasons, you or your insured spouse have the right to continue this insurance under the Portability provision, subject to certain conditions.
1Additional limitations apply as described in the certificate.
2Fractures and dislocations require treatment within 90 days of accident, burns and lacerations within 72 hours of an accident, and dental care within 30 days. If an insured person sustains both a fracture and dislocation as the result of the same accident, the maximum amount payable is up to 200% of the amount payable for the injury with the highest applicable benefit amount.
Are there any exclusions or limitations? The benefits payable are based on the insurance in effect on the date of the covered accident, subject to the definitions, limitations, exclusions and other provisions of the policy. The exclusions and limitations are summarized in the outline of coverage and detailed in the certificate. Please contact your benefits administrator for a copy of the outline of coverage or if you have questions prior to enrolling.
Childcare
Transportation (Up to 3 trips per accident) $450 Per trip $150 Per trip
HIGH PLAN LOW PLAN Follow Up Care1 Treatment / service required within 365 days of accident; Medical device is once per accident per insured person
3Daily confinement must begin with 90 days of accident and ICU confinement within 30 days. Surgical treatment timeframes vary. If applicable, diagnostic services must be received within 90 days of accident. Except for confinement benefits, most benefits are payable once per accident per insured person. If any surgery occurs concurrently with an open reduction for a fracture or dislocation of the same bone or joint as a result of the same accident, only the highest applicable benefit is payable.
Lodging (Up to 30 nights per accident) $150 Per night $100 Per night (Up to 30
days per accident) $30 Per day $20 Per day Catastrophic Benefits1,4 Benefits are payable within 365 days of accident; Once per accident per insured person Principal Sum (PS) You: $50,000 Spouse: $25,000 Child(ren): $10,000 You: $10,000 Spouse: $5,000 Child(ren): $5,000 Common Carrier Accidental Death 300% of PS 300% of PS Transportation of Remains Up to $5,000 Up to $5,000 Dismemberment & Paralysis Up to 100% of PS Up to 100% of PS Reasonable Modifications Up to 10% of PS Up to 10% of PS Coma 25% of PS 50% of PS HearingSERVICESDiscount Program The Hearing Discount program provides you and your family discounted hearing products, including hearing aids and batteries. Call (888) 534 1747 or visit www.amplifonusa.com/mutualofomaha to learn more. 16
What is the “Express Benefit”? This benefit is payable upon notification of an accident in which an insured person is injured. It can be paid in a short time frame with minimal information (compared to a typical claim).
4The principal sum for you and your spouse reduces by 50% when you reach the age of 70. Who is eligible for this insurance? You must be actively working (performing all normal duties of your job) at least 30 hours per week and be under age 80. Your dependent(s) must be performing normal activities and not be confined (at home or in a hospital / care facility) and any child(ren) must be under age 26.
Prosthetic Device(s) $1,000; Up to 2 per accident $500; Up to 2 per accident
ABOUT IDENTITY THEFT PROTECTION Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered. For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Identity Theft IDWatchdog EMPLOYEE BENEFITS Identity Theft Is Growing Better Protect You and Your Family Fraud continues to grow more complex. And, it is becoming harder for consumers and identity theft victims to manage the intricacies on their own. Fraudsters are taking advantage of consumers' increased digital dependence to steal personal and financial information doubling the amount of identity theft reports to the FTC in 2020.1 Easy & Affordable Identity Protection ID Watchdog helps warn you when your personal information is stolen and helps you better protect yourself and your family from identity fraud when stolen information is used for illicit gain. You’ll have greater peace of mind knowing you don’t have to face the complexities of identity theft alone. More for Families. Our family plan helps you better protect the identities of your loved ones of all ages. We offer more features that help protect minors than any other provider. IDWatchdog is here for you 24/7/365. Reach our in house customer care team at (866) 513 1518. Control & Manage • Financial Accounts & Social Account Monitoring • • • • Equifax Blocked Inquiry Alerts • Monitor & Detect • • • High Risk Transactions Monitoring2 • • Public Records Monitoring • USPS Change of Address Monitoring • Identity Profile Report • Credit Score Tracker Support & Restore • Fully Managed Resolution Services • • • • Credit FreezePlatinumAssistance Credit Report(s)4 & VantageScore Credit Score(s) Up to $1 Million 401K/HSA Stolen Funds Reimbursement6 ✓ ✓ Social Account Takeover Alerts ✓ Integrated Fraud Alerts7 ✓ Identity Theft1B Platinum Employee $7.95 $11.95 Employee and Family $14.95 $22.95 17
Disability Insurance OneAmerica EMPLOYEE BENEFITS
Flexible Choices: Since everyone's needs are different, these plans offer flexibility for you to choose a benefit option that fits your income replacement needs and budget. You are able to enroll and/or change plans during each scheduled enrollment.
Disability per $100 in benefit
Elimination Period 50% 60% $3.02 $3.02 $3.02 $3.55 $2.54 $2.54 $2.54 $2.99 30/30 $2.04 $2.04 $2.04 $2.40 60/60 $1.37 $1.37 $1.37 $1.61 90/90 $1.19 $1.19 $1.19 $1.37 180/180 $0.91 $0.91 $0.91 $1.07
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ABOUT DISABILITY
18
Enrolling later requires approval. If you decline coverage now, you will lose your only chance to apply for group insurance coverage without having to first undergo medical underwriting. If you decide to enroll later, you will need to submit a Statement of Insurability form for review. OneAmerica will then decide to approve or deny your coverage based on your health history. You may not be approved for any type of coverage at a later date if you have any current or future medical conditions.
Your premiums and benefits may vary. Actual premiums and benefit amounts will be calculated by OneAmerica and may change upon reaching certain ages, according to contract terms, and are subject to change.
Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.
Eligible Employees: This benefit is available for employees who are actively at work on the effective date and working a minimum of 30 hours per week.
Enrollage. timely for guaranteed issue coverage. You may be eligible for coverage without having to answer any health questions if you enroll during the initial enrollment period when benefits are first offered by OneAmerica®, or if you enroll as a newly hired employee within 31 days after any applicable waiting period.
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Portability: Should your coverage terminate, you may be eligible to take this disability insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible.
Waiver of Premium: If approved, this benefit waives your Disability insurance premium in case you become disabled and are unable to collect a paycheck.
Guaranteed Issue: If you enroll timely, you may be eligible for coverage without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you may need to provide Evidence of Insurability.
For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd
Timely Enrollment: Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.
What you need to know about your Educator Disability Benefits
30% 40%
Volumes and benefit amounts shown may be subject to reductions due to
Elimination Period: This is a period of consecutive days of disability before benefits may become payable under the contract. Benefit Duration: This is the length of time that you may be paid benefits if continuously disabled as outlined in the contract.
First Day Hospital: If a Person is Totally Disabled and hospital confined for 24 hours or more with room and board charges during the Elimination Period due to an Injury or Sickness resulting in a covered Disability, benefits are payable from the first day of that confinement. Applies to plans with Elimination Periods of 30 days or less.
About Your Benefits: Educator Disability benefits are illustrated and paid on a monthly basis.
Maximum
An offset is an amount that reduces your benefit amount by amounts you receive from other sources for your disability and will be specified in the contract. The pre existing period is 3/12. Certain disabilities are not covered if the cause of the disability is traceable to a condition existing prior to your effective date of coverage. A pre existing condition is any condition for which a person has received medical treatment or consultation, taken or were prescribed drugs or medicine, or received care or services, including diagnostic measures, within a timeframe specified in the contract. You must also be treatment free for a timeframe specified in some contracts following your individual effective date of coverage. A limited benefit will be paid if the Person’s Disability begins in the first 12 months following the Person’s Individual Effective Date of Insurance; and the Person’s Disability is caused by, contributed to by, or the result of a condition for which the Person received medical advice or treatment in the 3 months just prior to the Person’s Individual Effective Date of Insurance.
Pre Existing
What you need to know about your Educator Disability Benefits
Disability Insurance OneAmerica Educator Disability Options You may select a benefit percentage of 30%, 40%, 50% or 60% of your earnings, up to a maximum monthly benefit of $7,500. Elimination Period Maximum Benefit Duration Age When Total Disability Begins Maximum Duration Greater of Social Security Full Retirement Age or to age 65 Option 1: 7 days / 7 days Less than age 60 5 years Option 2: 14 days / 14 days 60 4 years Option 3: 30 days / 30 days 61 3.5 years Option 4: 60 days /60 days 62 3 years Option 5: 90 days / 90 days 63 2.5 years Option 6: 180 days/180 days 64 2 years 65 21 months 66 18 months 67 15 months 68 12 months 69 and over 19
Limitations:Condition
Life and AD&D Lincoln Financial Group EMPLOYEE BENEFITS ABOUT LIFE AND AD&D Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered. For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Voluntary Group Life per $10,000 in coverage Age Employee 18 24 $0.65 25 29 $0.65 30 34 $0.75 35 39 $1.05 40 44 $1.65 45 49 $2.35 50 54 $4.15 55 59 $6.35 60 64 $6.55 65 69 $11.95 70 74 $25.25 75 79 $75.35 80 99 $162.55 Voluntary Group Life Child(ren)$10,000 in coverage 0 26 $2.00 AD&D per $10,000 in coverage $0.25 Spouse rates based on Employee's age. 20
Life and AD&D Lincoln Financial Group EMPLOYEE BENEFITS 21
Basic Life Coverage Provided to eligible employees. A cash benefit of $50,000 to your loved ones in the event of your death, plus a matching cash benefit if you die in an accident. Guaranteed coverage amount for Self $200,000 Maximum coverage amount 5 times your annual salary ($500,000 maximum in increments of $10,000) AD&D coverage amount Equal to the life insurance amount chosen Guaranteed coverage amount for Spouse $50,000 Maximum coverage amount for Spouse 50% of the employee coverage amount ($250,000 maximum in increments of $5,000) AD&D coverage amount Equal to the life insurance amount chosen Guaranteed coverage amount for dependent children 6 months 26 years $10,000 Guaranteed coverage amount for dependent children 14 days 6 months $250 Guaranteed Life and AD&D Insurance Coverage Amount:
Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to $200,000 without providing evidence of insurability. If you submitted evidence of insurability in the past and were declined for medical reasons, you may be required to submit evidence of insurability. If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your own expense. You can increase this amount by up to $20,000 during the next limited open enrollment period.
Maximum Life Insurance Coverage Amount: You can choose a coverage amount up to 5 times your annual salary ($500,000 maximum) with evidence of insurability. See the Evidence of Insurability page for details. The maximum coverage amount for employees 70 and older who are electing coverage for the first time is $50,000. Your coverage amount will reduce by 35% when you reach age 65; an additional 25% of the original amount when you reach age 70; an additional 15% of the original amount when you reach age 75; and an additional 15% of the original amount when you reach age 80.
Dependent Children Coverage: You can secure term life insurance for your dependent children when you choose coverage for Guaranteedyourself.Life
Guaranteed Life and AD&D Insurance Coverage Amount:
Initial Open Enrollment: When you are first offered this coverage, you can choose a coverage amount up to 50% of your coverage amount ($50,000 maximum) for your spouse without providing evidence of insurability. If you submitted evidence of insurability in the past and were declined for medical reasons, you may be required to submit evidence of insurability. If you decline this coverage now and wish to enroll later, evidence of insurability may be required and may be at your own expense. You can increase this amount by up to $10,000 during the next limited open enrollment period.
Insurance Coverage Options: $10,000
Maximum Spouse Life Insurance Coverage Amount: You can choose a coverage amount up to 50% of your coverage amount ($250,000 maximum) for your spouse with evidence of insurability. Coverage amounts are reduced by 35% when an employee reaches age 65
ABOUT HOSPITAL INDEMNITY This is an affordable supplemental plan that pays you should you be in patient hospital confined. This plan complements your health insurance by helping you pay for costs left unpaid by your health insurance. For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Hospital Indemnity The Hartford EMPLOYEE BENEFITS Hospital IndemnityLOW HIGH Employee Only $14.16 $28.30 Employee and Spouse $25.24 $50.48 Employee and Child(ren) $25.58 $51.16 Employee and Family $38.56 $77.12 LOW HIGH Coverage Type On and off job (24 hour) On and off job (24 hour) Covered Events Illness and injury Illness and injury HSA Compatible Yes Yes BENEFITS LOW HIGH HOSPITAL CARE2 First Day ConfinementHospital Up to 1 day per year $1,000 $2,000 Daily ConfinementHospital(Day 2+) Up to 30 days per year $100 $200 VALUE ADDED SERVICES LOW HIGH Ability Assist® EAP4 24/7/365 access to help for financial, legal, or emotional issues Included Included HealthChampionSM5 Administrative & clinical support following serious illness or injury Included Included 22
WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your WHENemployer.DOES
AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured.
The initial effective date of this coverage is September 1, 2019. Subject to any eligibility waiting period established by your employer, if you enroll for coverage prior to this date, insurance will become effective on this date. If you enroll for coverage after this date, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility), unless already insured with the prior carrier.
Hospital
IS THIS COVERAGE HSA COMPATIBLE? If you (or any dependent(s)) currently participate in a Health Saving Account (HSA) or if you plan to do so in the future, you should be aware that the IRS limits the types of supplemental insurance you may have in addition to a HSA, while still maintaining the tax exempt status of the HSA. This plan design was designed to be compatible with Health Savings Accounts (HSAs). However, if you have or plan to open an HSA, please consult your tax and legal advisors to determine which supplemental benefits may be purchased by employees with an HSA.
WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis.
Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26.
WHEN DOES THIS INSURANCE END? This insurance will end when you or your dependent(s) no longer satisfy the applicable eligibility conditions, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered.
THIS INSURANCE BEGIN?
CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances. This insurance coverage includes certain limitations and exclusions. The certificate details all provisions, limitations, and exclusions for this insurance coverage. A copy of the certificate can be obtained from your employer.
Indemnity The Hartford EMPLOYEE BENEFITS 23
HOW DO I PAY FOR THIS INSURANCE? Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment.
CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER? Yes. Any reference to “spouse” includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law.
Critical Illness $10,000 Plan Employee Only Employee & Spouse Employee & Children Employee & Family Under 25 $3.62 $5.88 $7.34 $10.20 25 29 $4.40 $7.04 $7.82 $11.02 30 34 $4.90 $7.80 $7.80 $11.20 35 39 $6.14 $9.68 $8.76 $12.74 40 44 $8.48 $13.28 $10.84 $16.02 45 49 $12.96 $20.22 $15.26 $22.90 50 54 $17.86 $27.87 $20.08 $30.42 55 59 $24.22 $37.72 $26.42 $40.30 60 64 $33.94 $52.80 $36.12 $55.32 65 69 $46.26 $71.56 $48.42 $74.10 70 74 $61.18 $94.44 $63.34 $96.98 75 79 $79.64 $122.48 $81.82 $125.02 $30,000 Plan Employee Only Employee & Spouse Employee & Children Employee & Family Under 25 $8.96 $13.90 $18.42 $24.92 25 29 $11.14 $17.12 $19.72 $27.12 30 34 $12.58 $19.28 $19.60 $27.48 35 39 $16.30 $24.86 $22.44 $32.02 40 44 $23.18 $35.34 $28.52 $41.58 45 49 $36.48 $55.88 $41.64 $61.92 50 54 $51.16 $78.60 $56.12 $84.44 55 59 $70.22 $108.30 $75.12 $114.04 60 64 $99.40 $153.52 $104.22 $159.14 65 69 $136.32 $209.80 $141.14 $215.42 70 74 $181.08 $278.46 $185.90 $284.08 75 79 $236.46 $362.58 $241.28 $368.20 ABOUT CRITICAL ILLNESS Critical illness insurance can be used towards medical or other expenses. It provides a lump sum benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke. The money can also be used for non medical costs related to the illness, including transportation, child care, etc. For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Critical Illness Insurance The Hartford EMPLOYEE BENEFITS Facing a serious illness can be devastating both emotionally and financially. Major medical insurance may pick up most of the tab but can still leave out of pocket expenses that add up quickly. Critical Illness insurance can provide a lump sum benefit upon diagnosis that can be used however you choose from expenses related to treatment, to deductibles or day to day costs of living such as the mortgage or your utility bills. 24
Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain GROUPcircumstances.CRITICAL
• A covered person's participation in a felony, riot or insurrection
• A covered person's service in the armed forces or units auxiliary to them
General Limitations. Benefits under the policy are not payable for any covered illness:
• Diagnosed during an applicable benefit separation period
COVERAGE
• Suicide, attempted suicide, or intentionally self inflicted injury, whether sane or insane
The benefits payable are based on the insurance in effect on the date of the diagnosis of a covered illness, subject to the definitions, limitations, exclusions and other provisions of the policy. You and your dependent(s) must be citizens or legal residents of the United States, its territories and protectorates.
WHEN DOES THIS INSURANCE END? This insurance will end when you or your dependent(s) no longer satisfy the applicable eligibility conditions, or when you reach the age of 80, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer CANoffered.IKEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this coverage with you.
ILLNESS INSURANCE LIMITATIONS AND EXCLUSIONS
• For which a covered person has already received a benefit payment under the policy, unless the covered illness is included in a recurrence provision
• For which a covered person has already received a benefit payment under the recurrence provision In addition, benefits are not payable for any critical illness not included as a covered illness in your certificate.
Hartford EMPLOYEE
• War or act of war, declared or undeclared
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WHEN DOES THIS INSURANCE BEGIN? The initial effective date of this coverage is September 1, 2019. Subject to any eligibility waiting period established by your employer, if you enroll for coverage prior to this date, insurance will become effective on this date. If you enroll for coverage after this date, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility), unless already insured with the prior carrier.
Exclusions. This insurance does not provide benefits for any loss that results from or is caused by:
Critical Illness Insurance
• Diagnosed prior to the effective date of insurance for a covered person (except for newborn children)
• A covered person's engaging in any illegal occupation
COVERAGE AMOUNTS Employee Coverage Amount $10,000 or $30,000 Spouse Coverage Amount Greater of $5,000 or 50% of your coverage amount Child(ren) Coverage Amount 50% of your coverage amount COVERED ILLNESSES BENEFIT AMOUNTS CANCER CONDITIONS Benign Brain Tumor*; Invasive Cancer* 100% of coverage amount Non invasive Cancer 25% of coverage amount VASCULAR CONDITIONS Heart Attack*; Heart Transplant*; Stroke* 100% of coverage amount Aneurysm; Angioplasty/Stent; Coronary Artery Bypass Graft 25% of coverage amount OTHER SPECIFIED CONDITIONS Coma*; End Stage Renal Failure; Loss of Hearing; Loss of Speech; Loss of Vision; Major Organ Transplant*; Paralysis 100% of coverage amount Bone Marrow Transplant 25% of coverage amount NEUROLOGICAL CONDITIONS Advanced Multiple Sclerosis; Advanced Parkinson’s; Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s); 100% of coverage amount CHILD CerebralCONDITIONSPalsy;Congenital Heart Disease; Cystic Fibrosis; Muscular Dystrophy; Spina Bifida 100% of coverage amount ADDITIONAL BENEFITS BENEFIT AMOUNTS Recurrence Pays a benefit for a subsequent diagnosis of conditions marked with an asterisk (*) 100% of original benefit amount Health Screening Benefit $50 once per year per covered person FEATURES DETAILS Coverage Maximum Primary Insured & Spouse/Partner 500% of coverage amount Coverage Maximum Child(ren) 300% of coverage amount Ability Assist® EAP2 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM2 Administrative and clinical support following serious illness or injury WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis and are less than age 80. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26. AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured. WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your employer.
The BENEFITS INFORMATION: Benefit amounts for covered illnesses are based on the coverage amount in effect for you or an insured dependent at the time of diagnosis.
Transport MASA EMPLOYEE BENEFITS
A MASA MTS Membership provides the ultimate peace of mind at an affordable rate for emergency ground and air transportation service within the United States and Canada, regardless of whether the provider is in or out of a given group healthcare benefits network. If a member has a high deductible health plan that is compatible with a health savings account, benefits will become available under the MASA membership for expenses incurred for medical care (as defined under Internal Revenue Code (“IRC”) section 213 (d)) once a member satisfies the applicable statutory minimum deductible under IRC section 223(c) for high deductible health plan coverage that is compatible with a health savings account.
Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out of pocket costs that are not covered by insurance. It can include emergency transportation via ground ambulance, air ambulance and helicopter, depending on the plan.
Emergent Air Transportation
Non Emergency Inter Facility Transportation
In the event that a member is in stable condition in a medical facility but requires a heightened level of care that is not available at their current medical facility, Members have access to non emergency air or ground transportation between medical
Emergency Medical
For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd
In the event of a serious medical emergency, Members have access to emergency air transportation into a medical facility or between medical facilities. Emergent Ground Transportation
In the event of a serious medical emergency, Members have access to emergency ground transportation into a medical facility or between medical facilities.
SupposeRepatriation/Recuperationfacilities.youorafamilymember is hospitalized more than 100 miles from your home. In that case, you have benefit coverage for air or ground medical transportation into a medical facility closer to your home for recuperation. Should you need assistance with a claim contact MASA at 800 643 9023. You can find full benefit details at: www.mybenefitshub.com/andrewsisd
Emergency MedicalEmergentTransportationPlusPlatinum Employee & Family $14.00 $39.00 Plan FeaturesEmergentMembershipPlus MembershipPlatinum Emergency TransportationAir x x Emergent Ground Transportation x x Non Emergency Inter Facility Transportation x x RecuperationRepatriation/ x x Escort Transportation x Visitor Transportation x Return Transportation x Mortal TransportationRemains x Minor Return x Organ RecipientRetrieval/OrganTransportation x Vehicle Return x Pet Return x Worldwide Coverage x 26
ABOUT MEDICAL TRANSPORT
ABOUT TELEHEALTH Telehealth provides 24/7/365 access to board certified doctors via telephone or video consultations that can diagnose, recommend treatment and prescribe medication. Telehealth makes care more convenient and accessible for non emergency care when your primary care physician is not available. For full plan details, please visit your benefit website: www.mybenefitshub.com/andrewsisd Telehealth MDLive EMPLOYEE BENEFITS Telehealth Alongside your medical coverage is access to quality telehealth services through MDLIVE. Connect anytime day or night with a board certified doctor via your mobile device or computer. While MDLIVE does not replace your primary care physician, it is a convenient and cost effective option when you need care and: • Have a non emergency issue and are considering a convenience care clinic, urgent care clinic • or emergency room for treatment • Are on a business trip, vacation or away from home • Are unable to see your primary care physician When to Use MDLIVE At a cost that is the same or less than a visit to your physician, use telehealth services for minor conditions such as: Do not use telemedicine for serious or life threatening emergencies. Registration is Easy Register with MDLIVE so you are ready to use this valuable service when and where you need it. • Online www.mdlive.com/fbs • Phone (888) 365 1663 • Mobile download the MDLIVE mobile app to your smartphone or mobile device • Select “MDLIVE as a benefit” and “FBS” as your Employer/Organization when registering your • account. Telehealth Employee and Family $10.00 • Sore throat • Headache • Stomachache • Cold • Flu • Allergies • Fever • Urinary tract infections 27
Rate Sheet General Disclaimer: The rate information provided in this guide is subject to change at any time by your employer and/or the plan provider. The rate information included herein, does not guarantee coverage or change or otherwise interpret the terms of the specific plan documentation, available at the Andrews ISD Benefits Website, which may include additional exclusions and limitations and may require an application for coverage to determine eligibility for the health benefit plan. To the extent the information provided in this summary is inconsistent with the specific plan documentation, the provisions of the specific plan documentation will govern in all cases.
WWW.MYBENEFITSHUB.COM/ANDREWSISD
2021 - 2022 PlanYear
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Enrollment Guide General Disclaimer: This summary of benefits for employees is meant only as a brief description of some of the programs for which employees may be eligible. This summary does not include specific plan details. You must refer to the specific plan documentation for specific plan details such as coverage expenses, limitations, exclusions, and other plan terms, which can be found at the Andrews ISD Benefits Website. This summary does not replace or amend the underlying plan documentation. In the event of a discrepancy between this summary and the plan documentation the plan documentation governs. All plans and benefits described in this summary may be discontinued, increased, decreased, or altered at any time with or without notice.
